MEDICARE: BRIDGEWAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1215707872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWAY

Provider Business Mailing Address
First Line	:	1501 W BROADWAY AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2473
Country	:	US
Telephone Number	:	507-405-6608
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 W BROADWAY AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55411-2473
Country	:	US
Telephone Number	:	507-405-6608
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HASSAN SHARIFF OSMAN
Credential	:
Telephone Number	:	507-405-6608

Provider Enumeration Date	:	01/04/2024
Last Update Date	:	01/04/2024

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Directions to “BRIDGEWAY ” Practice Location

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